Healthcare Provider Details

I. General information

NPI: 1730786104
Provider Name (Legal Business Name): JOSEPH WILLIAM RUSSO DNP, CPNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

3401 GERBER DAISY LN
OVIEDO FL
32766-6689
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-5437
  • Fax:
Mailing address:
  • Phone: 203-731-4169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberR196579
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN11012765
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: